Original article 233
Prevalence of delirium in geriatric rehabilitation in Israel and its influence on rehabilitation outcomes in patients with hip fractures Neomi Heymana, Frances Nilia, Ron Shahorya, Irena Selezneva and Merav Ben Natanb The aim of this study was to assess the prevalence of delirium among geriatric patients with hip fractures and to examine the influence of delirium on rehabilitation outcomes. A prospective study was carried out among 95 hip fracture patients admitted to an orthopedic geriatric rehabilitation ward. At admission, the following data were gathered: sociodemographic data, prefracture Activities of Daily Living (ADL), Functional Independence Measure (FIM), Mini-Mental State Examination, comorbidities, and medication. Delirium was assessed using the Confusion Assessment Method. The severity of delirium among patients with a positive score on the Confusion Assessment Method was assessed using the Delirium Rating ScaleRevised-98 (DRS-R-98). Rehabilitation outcomes were evaluated by comparing FIM and ADL at admission and at discharge. The research findings showed that the prevalence of delirium among patients was 30%. In addition, a significant difference was found between patients who developed delirium and those who did not. Patients who developed delirium were mostly Jewish, with lower ADL levels at admission, more significant renal failure, lower
Introduction Hip fractures are one of the most serious injuries that lead to reduced functioning among the elderly, impair independence, increase hospitalizations at long-term care facilities, and increase the risk of further morbidity and mortality (Ranhoff et al., 2010). In Israel, ∼ 6000 individuals sustain hip fractures each year, out of a total population of 8 296 000, for a rate of 72.3 per 100 000 (Israel Central Bureau of Statistics, 2014). This is a high rate, and with the increase in life expectancy, the number of hip fractures is expected to double by 2040 (Haentjens et al., 2001; Zidén et al., 2008). Delirium is a common and severe complication among elderly in patients and among other patients following hip fracture surgery. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), delirium is defined by a range of symptoms, including disturbed consciousness, reduced ability to focus, sustain, or shift attention, altered cognition or a perceptual disturbance, and acute onset and fluctuating symptoms, which can be mild and fleeting, or severe and persistent. Lethargy, mood changes, and an altered sleep–wake 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
levels of FIM, and lower Mini-Mental State Examination scores. Furthermore, FIM at discharge and delta FIM were lower among patients who developed delirium than among those who did not. The research conclusions indicated that the functional recovery of patients with delirium is slower. Therefore, it is important to adjust the therapeutic approach to these patients. International Journal of Rehabilitation Research 38:233–237 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:233–237 Keywords: delirium, geriatric rehabilitation outcomes, hip fracture, Israel a Department of Geriatrics, Shoham Medical Center, affiliated with the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa and bNursing Department, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
Correspondence to Merav Ben Natan, PhD, Pat Mattews Academic School of Nursing, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100 Israel Tel: + 972 4 6304367/9; fax: + 972 4 6304730; e-mail: [email protected] Received 14 April 2015 Accepted 24 May 2015
cycle can also occur, although are not required to establish a diagnosis (Wass et al., 2008). A systematic review of the literature performed by Siddiqi et al. (2006) showed that the prevalence of delirium among elderly individuals upon their admission to in-patient care ranged from 10 to 40% in the various studies. During their hospital stay, another 25–50% of patients were affected by this condition. Delirium is a medical emergency; a lack of early detection and a failure to treat delirium and its causes among the elderly may lead to an increase in mortality, an increase in hospitalization costs, and a decrease in functional abilities. The prevalence of delirium-related mortality was high, ranging between 14.5 and 37% (Siddiqi et al., 2006). One of the underlying problems was the difficulty encountered by physicians at hospitals and rehabilitation facilities in detecting delirium. A questionnaire administered to 912 medical professionals (physicians and nurses) found that over 78% did not diagnose delirium properly. In all, 40% reported that they knew how to diagnose delirium, but only half used designated diagnostic tools to diagnose delirium (Wiesel et al., 2011). DOI: 10.1097/MRR.0000000000000121
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234 International Journal of Rehabilitation Research 2015, Vol 38 No 3
Presumably, the delirium syndrome was characterized by insufficient diagnosis and a lack of adequate documentation, hampering the quality of care provided and patient outcomes (Ely et al., 2004). Previous studies have not provided definitive evidence as to the influence of delirium on rehabilitation outcomes. The aim of the present study was to assess the prevalence of delirium among hip fracture patients hospitalized in a rehabilitation ward and to examine the influence of delirium on rehabilitation outcomes.
Methods The study was a prospective study carried out among hip fracture patients admitted to a single rehabilitation ward at the Shoham Geriatric Centre in Pardes Hanna, Israel, from June 2014 to December 2014. This 556-bed government-owned facility is the largest of its kind in Israel. The research protocol was approved by the geriatric center’s Helsinki Committee. Inclusion criteria were as follows: patients 65 years of age and older admitted to the rehabilitation ward with a hip fracture, and ability to speak and understand Hebrew. Patients received physical therapy, occupational therapy, and assistance to regain mobility. Five patients declined to participate. The reasons provided were because of their perception that the study impinged on their privacy. Upon admission to the ward, the following data were gathered: sociodemographic data, prefracture Activities of Daily Living (ADL), Functional Independence Measure (FIM), Mini-Mental State Examination (MMSE), comorbidities, and medication. ADL served as a tool for evaluating the independent performance of basic functions. In the first 24 h after admission to the ward, patients underwent a clinical and functional evaluation. Data were gathered from medical records and from clinical interviews and with family members. Basic information included demographics – age, sex, ethnic origin, place of residence, prefracture functional state, comorbidities, and regular medication. Cognitive state upon admission was examined using the MMSE, and delirium was assessed using the Confusion Assessment Method (CAM). This tool was found to have a high sensitivity (94–100%) and an α Cronbach of 0.82 (Inouye et al., 1990). In the case of patients with a positive CAM score and patients with a CAM score indicating suspicions of delirium (i.e. when one of the primary CAM criteria and one or two of the secondary criteria were positive), the severity of the delirium was evaluated using the Delirium Rating Scale-Revised-98 (DRS-R-98), a tool for diagnosing and evaluating the severity of delirium. The α Cronbach of the DRS-R-98 is high, 0.90 (Trzepacz et al., 2001). The delirium was reassessed once a week using the DRS-R-98 until it disappeared or until discharge. All patient assessment was performed in Hebrew. It is a standard practice in Israel to assess
delirium using the MMSE together with the CAM and the DRS-R-98. At discharge, functional progress during rehabilitation was evaluated by comparing FIM and ADL at admission and at discharge. The length of the hospital stay was calculated and the discharge goal was documented. This study focused on the presence or absence of delirium without discussing treatment for delirium. Data analyses
In this study, the mean, SDs, and frequencies of the different variables were calculated. A χ2-test and a t-test were used for unpaired variables, and a Fisher’s exact test was used to compare proportions when the data to be compared included less than five cases. Data processing was performed using SPSS (Chicago, Illinois, USA), version 19.
Results A total of 30% of the 95 patients developed delirium during their hospital stay. Sixty-two (65.3%) of the patients were women, with a mean age of 80.2 years (SD = 7.5) and an age range of 65–94 years. There was a significant difference in respondents’ age between those who developed delirium and those who did not [t(92) = − 2.2, P < 0.05]. The mean age of the patients who developed delirium was higher, 83.7 years (SD = 8.4), compared with patients who did not develop delirium, whose mean age was 79.4 years (SD = 7). Sixty-eight (71.6%) of the respondents were Jewish and 27 (28.4%) were Arab. There was a significant difference in patients’ ethnic origins between those who developed delirium and those who did not [χ2(1, N = 95) = 3.8, P < 0.05]. Of those who developed delirium, 89.5% were Jewish, whereas 66% of the patients who did not develop delirium were Arab. Fifty-six (58.9%) of the patients were functionally debilitated, requiring assistance with ADL before their hospitalization, 33 (34.7%) were functionally independent, and only six (6.3%) required nursing care. Upon admission to the ward, 72 (75.8%) of the patients required nursing care and 33 (24.2%) were functionally debilitated. There was a significant difference in ADL levels at admission between those who developed delirium and those who did not [χ2(1, N = 95) = 4.7, P < 0.05]. Of all patients who developed delirium, 94.7% required nursing care, whereas only 70.7% of those who did not develop delirium required nursing care (Table 1). Eighty-four (88.4%) of the patients had hypertension. Eighteen (18.9%) patients had ischemic heart disease. Twenty patients (21.1%) had experienced a stroke. Thirty-five (36.8%) patients had diabetes. Twenty (21.5%) patients had significant renal failure, defined as a Creatinine Clearance Test (CCT) rate assessed as less than 40. The CCT mean was 63 (SD = 24.7), with a range of 10–99, and a significant mean difference in the estimated CCT between patients who developed and did
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Delirium and rehabilitation Heyman et al. 235
Table 1
Differences in the functioning (ADL) of patients who developed delirium and patients who did not develop delirium
ADL at admission Patients who did not develop delirium Patients who developed delirium ADL at discharge Patient who did not develop delirium Patients who developed delirium
Requires nursing care [n (%)]
Debilitated [n (%)]
χ2
d.f.
Significance
53 (70.7) 18 (90)
22 (29.3) 2 (10)
4.7
1
> 0.05
23 (41.1) 15 (75)
33 (58.9) 5 (25)
5.7
1
> 0.05
ADL, Activities of Daily Living.
not develop delirium [t(92) = 2, P < 0.05]. Patients who developed delirium had a lower mean CCT [M = 53.1 (SD = 23.4)], than patients who did not develop delirium [M = 65.7 (SD = 24.7)]. Fifty-seven (60%) of the patients had comorbidities, with more than three significant diseases (diabetes, cardiovascular diseases, stroke, and renal failure). No significant difference was found in comorbidities between patients who developed delirium and those who did not (P > 0.05). Twenty-one (22.1%) patients had previous fractures. The mean BMI of patients was 26.5 (SD = 6.7), with a range of 17–49. Seventy-five (78.9%) patients took hypertension medication. Fifty-four (56.7%) patients took narcotics. Thirty-one (32.6%) patients took benzodiazepines. At admission, 20 (21.5%) patients developed delirium. This included four patients who developed full delirium according to the CAM and DRS-R-98 criteria and 16 patients who developed subsyndrome delirium. The mean duration of the patients’ delirium was 21.9 days (SD = 14.6), with a range of 7–54 days. Nine (8.5%) patients developed delirium on the last day of hospitalization. There was a significant difference between patients who did not develop delirium and those who developed delirium in their level of FIM at admission [t(92) = 2.8, P < 0.01]. The mean FIM at admission was lower among patients who developed delirium (M = 51.6, SD = 16.3) than among patients who did not develop delirium (M = 64.1, SD = 17.2). Twenty-seven patients had a cognitive impairment of under 23 MMSE at the time of admission. There a significant difference between patients who did not develop delirium and those who did develop delirium [t(90) = 3.8, P < 0.05], with the MMSE at admission having been on average lower among patients who developed delirium (M = 12.6, SD = 6.3) than among patients who did not develop delirium (M = 19.3, SD = 8.1). Significant differences were found in the rehabilitation outcomes of the two groups on several parameters, as presented in Table 2. FIM at discharge and delta FIM were higher among patients who did not develop delirium compared with patients who did develop delirium. Overall, 75% of patients who developed delirium required nursing care at discharge, whereas only 41.1% of the patients who did not develop delirium required
Differences in FIM and DFIM as well as length of hospital stay between patients who developed/did not develop delirium
Table 2
Fracture patients who developed delirium
FIM at discharge Delta FIM Hospital stay (days)
Fracture patients who did not develop delirium
SD
M
SD
M
t
d.f.
18.3
62.4
20.5
83.9
Significance 0.01
3.7
71
13.1 10.7
10.5 29.5
15.4 14.4
19.4 28.1
0.05 > 0.05
2.3
71
DFIM, delta Functional Independence Measure; FIM, Functional Independence Measure.
nursing care [χ2(1, N = 95) = 4.7, P < 0.05]. No significant difference was found between the hospital stay duration of patients who developed delirium and those who did not. Moreover, no significant difference was found between patients who were discharged to their homes and those who were discharged to other facilities (P > 0.05).
Discussion The research findings showed that about 30% of patients hospitalized in a rehabilitation ward following a hip fracture developed delirium during their hospital stay. This prevalence was similar to that reported by Schuurmans et al. (2003), who found that 27 of 92 patients at a geriatric rehabilitation ward developed delirium. Nonetheless, other studies reported a higher prevalence. Radinovic et al. (2014) reported that 53% of hip fracture patients older than 70 years had delirium during their hospital stay at an orthopedic ward. Meta-analyses carried out among hip fracture patients who developed delirium indicated a widely diverse prevalence. Variable prevalence was also reported as evident from the systematic literature review of Siddiqi et al. (2006), who found that the prevalence of new delirium cases among in-patients ranged from 3 to 29%. Olofsson et al. (2005) presumed that the variance in the prevalence of delirium in various studies of elderly hip fracture patients may have been associated with factors such as inclusion criteria and the ability to detect delirium. Delirium still appears to be an underdiagnosed clinical syndrome. The transient and varying nature of the symptoms and the heterogeneous profile of delirium, with its different subtypes, contribute
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236 International Journal of Rehabilitation Research 2015, Vol 38 No 3
toward this underdiagnosis (Witlox et al., 2010; Inouye et al., 2014).
disruption of neuron functioning, which may explain the appearance of delirium.
The research findings indicated several risk factors for developing delirium among posthip fracture elderly patients in geriatric rehabilitation. These could be categorized as sociodemographic, functional, and cognitive risk factors. Two sociodemographic risk factors were older age and being Jewish. The current study found that patients who developed delirium were on average older than patients who did not. Indeed, studies have shown that older age is a known risk factor for delirium among hip fracture patients (Schuurmans et al., 2003). Jewish patients had a higher risk of developing delirium. There were no other significant differences between Arabs and Jews that can explain the difference in the prevalence of delirium between the two populations. No studies were found on differences between Arabs and Jews in the incidence of delirium. This difference may have been a result of the difficulty in detecting delirium among Arab patients because of difficulties in fully communicating with patients who speak Arabic as their first language. The diagnostic tools for delirium may also not be suited to the Arab culture (Inouye et al., 1990).
The research findings indicated better rehabilitation outcomes among patients who did not develop delirium. FIM at discharge and delta FIM were higher among patients who did not develop delirium than among those who did. Furthermore, a different level of basic ADL functioning at discharge was observed, that is, more patients who developed delirium required nursing care at discharge. These findings showed better rehabilitation outcomes among hip fracture patients who did not develop delirium than among those who did. Many studies have indicated the association between delirium and various measures of rehabilitation outcomes (Olofsson et al., 2005; Siddiqi et al., 2006; Guerini et al., 2010; Witlox et al., 2010; Martinez Velilla and Franco, 2012; Cole et al., 2013; Liang et al., 2014; Uriz-Otano et al., 2014). Nonetheless, the exact mechanisms responsible for the association observed between delirium and poor rehabilitation outcomes among patients who developed delirium have not been clear. Several explanations were suggested for this finding: one of these was that a prolonged episode of delirium might contribute toward higher morbidity and complications, which may have led to poor rehabilitation outcomes. The duration of the symptoms might have indicated that the basic disease was still active or has worsened. Alternately, the delirium itself or the factors that stimulated the delirium syndrome may have led to a chain of events in the brain, possibly hampering the patient’s rehabilitation capacity (Witlox et al., 2010). The presence of dementia may itself have been detrimental to the rehabilitation process because of cognitive deprivation, such as of executive ability, memory, and attention. The combination of dementia with the delirium syndrome may have led to severe cognitive deterioration. This severe deterioration may have been responsible for poor rehabilitation outcomes among elderly hip fracture patients (Morandi et al., 2014). Another explanation for this finding may have been rooted in caregivers and particularly the nursing staff, who considered delirious patients with cognitive and nursing care deterioration to be more dependent and to require more complex nursing care. This recognition led the nursing staff to provide care that perpetuated the patient’s dependency to save time and labor, and thus they did not provide these patients the opportunity to perform daily activities at their own pace, thereby creating a state of dependency (Olofsson et al., 2005).
Functional risk factors for delirium were lower FIM at admission and lower prehospitalization ADL. In the current study, patients who developed delirium had on average a lower FIM at admission than patients who did not develop delirium. A larger proportion of patients who developed delirium required nursing care at admission than patients who did not develop delirium. Similar to other studies carried out among hip fracture patients (Olofsson et al., 2005; Radinovic et al., 2014), this study found that older patients in a poorer physical state had a higher risk of developing delirium following a hip fracture. The current study found that patients with cognitive impairment (MMSE
Prevalence of delirium in geriatric rehabilitation in Israel and its influence on rehabilitation outcomes in patients with hip fractures Neomi Heymana, Frances Nilia, Ron Shahorya, Irena Selezneva and Merav Ben Natanb The aim of this study was to assess the prevalence of delirium among geriatric patients with hip fractures and to examine the influence of delirium on rehabilitation outcomes. A prospective study was carried out among 95 hip fracture patients admitted to an orthopedic geriatric rehabilitation ward. At admission, the following data were gathered: sociodemographic data, prefracture Activities of Daily Living (ADL), Functional Independence Measure (FIM), Mini-Mental State Examination, comorbidities, and medication. Delirium was assessed using the Confusion Assessment Method. The severity of delirium among patients with a positive score on the Confusion Assessment Method was assessed using the Delirium Rating ScaleRevised-98 (DRS-R-98). Rehabilitation outcomes were evaluated by comparing FIM and ADL at admission and at discharge. The research findings showed that the prevalence of delirium among patients was 30%. In addition, a significant difference was found between patients who developed delirium and those who did not. Patients who developed delirium were mostly Jewish, with lower ADL levels at admission, more significant renal failure, lower
Introduction Hip fractures are one of the most serious injuries that lead to reduced functioning among the elderly, impair independence, increase hospitalizations at long-term care facilities, and increase the risk of further morbidity and mortality (Ranhoff et al., 2010). In Israel, ∼ 6000 individuals sustain hip fractures each year, out of a total population of 8 296 000, for a rate of 72.3 per 100 000 (Israel Central Bureau of Statistics, 2014). This is a high rate, and with the increase in life expectancy, the number of hip fractures is expected to double by 2040 (Haentjens et al., 2001; Zidén et al., 2008). Delirium is a common and severe complication among elderly in patients and among other patients following hip fracture surgery. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), delirium is defined by a range of symptoms, including disturbed consciousness, reduced ability to focus, sustain, or shift attention, altered cognition or a perceptual disturbance, and acute onset and fluctuating symptoms, which can be mild and fleeting, or severe and persistent. Lethargy, mood changes, and an altered sleep–wake 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
levels of FIM, and lower Mini-Mental State Examination scores. Furthermore, FIM at discharge and delta FIM were lower among patients who developed delirium than among those who did not. The research conclusions indicated that the functional recovery of patients with delirium is slower. Therefore, it is important to adjust the therapeutic approach to these patients. International Journal of Rehabilitation Research 38:233–237 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:233–237 Keywords: delirium, geriatric rehabilitation outcomes, hip fracture, Israel a Department of Geriatrics, Shoham Medical Center, affiliated with the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa and bNursing Department, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
Correspondence to Merav Ben Natan, PhD, Pat Mattews Academic School of Nursing, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100 Israel Tel: + 972 4 6304367/9; fax: + 972 4 6304730; e-mail: [email protected] Received 14 April 2015 Accepted 24 May 2015
cycle can also occur, although are not required to establish a diagnosis (Wass et al., 2008). A systematic review of the literature performed by Siddiqi et al. (2006) showed that the prevalence of delirium among elderly individuals upon their admission to in-patient care ranged from 10 to 40% in the various studies. During their hospital stay, another 25–50% of patients were affected by this condition. Delirium is a medical emergency; a lack of early detection and a failure to treat delirium and its causes among the elderly may lead to an increase in mortality, an increase in hospitalization costs, and a decrease in functional abilities. The prevalence of delirium-related mortality was high, ranging between 14.5 and 37% (Siddiqi et al., 2006). One of the underlying problems was the difficulty encountered by physicians at hospitals and rehabilitation facilities in detecting delirium. A questionnaire administered to 912 medical professionals (physicians and nurses) found that over 78% did not diagnose delirium properly. In all, 40% reported that they knew how to diagnose delirium, but only half used designated diagnostic tools to diagnose delirium (Wiesel et al., 2011). DOI: 10.1097/MRR.0000000000000121
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234 International Journal of Rehabilitation Research 2015, Vol 38 No 3
Presumably, the delirium syndrome was characterized by insufficient diagnosis and a lack of adequate documentation, hampering the quality of care provided and patient outcomes (Ely et al., 2004). Previous studies have not provided definitive evidence as to the influence of delirium on rehabilitation outcomes. The aim of the present study was to assess the prevalence of delirium among hip fracture patients hospitalized in a rehabilitation ward and to examine the influence of delirium on rehabilitation outcomes.
Methods The study was a prospective study carried out among hip fracture patients admitted to a single rehabilitation ward at the Shoham Geriatric Centre in Pardes Hanna, Israel, from June 2014 to December 2014. This 556-bed government-owned facility is the largest of its kind in Israel. The research protocol was approved by the geriatric center’s Helsinki Committee. Inclusion criteria were as follows: patients 65 years of age and older admitted to the rehabilitation ward with a hip fracture, and ability to speak and understand Hebrew. Patients received physical therapy, occupational therapy, and assistance to regain mobility. Five patients declined to participate. The reasons provided were because of their perception that the study impinged on their privacy. Upon admission to the ward, the following data were gathered: sociodemographic data, prefracture Activities of Daily Living (ADL), Functional Independence Measure (FIM), Mini-Mental State Examination (MMSE), comorbidities, and medication. ADL served as a tool for evaluating the independent performance of basic functions. In the first 24 h after admission to the ward, patients underwent a clinical and functional evaluation. Data were gathered from medical records and from clinical interviews and with family members. Basic information included demographics – age, sex, ethnic origin, place of residence, prefracture functional state, comorbidities, and regular medication. Cognitive state upon admission was examined using the MMSE, and delirium was assessed using the Confusion Assessment Method (CAM). This tool was found to have a high sensitivity (94–100%) and an α Cronbach of 0.82 (Inouye et al., 1990). In the case of patients with a positive CAM score and patients with a CAM score indicating suspicions of delirium (i.e. when one of the primary CAM criteria and one or two of the secondary criteria were positive), the severity of the delirium was evaluated using the Delirium Rating Scale-Revised-98 (DRS-R-98), a tool for diagnosing and evaluating the severity of delirium. The α Cronbach of the DRS-R-98 is high, 0.90 (Trzepacz et al., 2001). The delirium was reassessed once a week using the DRS-R-98 until it disappeared or until discharge. All patient assessment was performed in Hebrew. It is a standard practice in Israel to assess
delirium using the MMSE together with the CAM and the DRS-R-98. At discharge, functional progress during rehabilitation was evaluated by comparing FIM and ADL at admission and at discharge. The length of the hospital stay was calculated and the discharge goal was documented. This study focused on the presence or absence of delirium without discussing treatment for delirium. Data analyses
In this study, the mean, SDs, and frequencies of the different variables were calculated. A χ2-test and a t-test were used for unpaired variables, and a Fisher’s exact test was used to compare proportions when the data to be compared included less than five cases. Data processing was performed using SPSS (Chicago, Illinois, USA), version 19.
Results A total of 30% of the 95 patients developed delirium during their hospital stay. Sixty-two (65.3%) of the patients were women, with a mean age of 80.2 years (SD = 7.5) and an age range of 65–94 years. There was a significant difference in respondents’ age between those who developed delirium and those who did not [t(92) = − 2.2, P < 0.05]. The mean age of the patients who developed delirium was higher, 83.7 years (SD = 8.4), compared with patients who did not develop delirium, whose mean age was 79.4 years (SD = 7). Sixty-eight (71.6%) of the respondents were Jewish and 27 (28.4%) were Arab. There was a significant difference in patients’ ethnic origins between those who developed delirium and those who did not [χ2(1, N = 95) = 3.8, P < 0.05]. Of those who developed delirium, 89.5% were Jewish, whereas 66% of the patients who did not develop delirium were Arab. Fifty-six (58.9%) of the patients were functionally debilitated, requiring assistance with ADL before their hospitalization, 33 (34.7%) were functionally independent, and only six (6.3%) required nursing care. Upon admission to the ward, 72 (75.8%) of the patients required nursing care and 33 (24.2%) were functionally debilitated. There was a significant difference in ADL levels at admission between those who developed delirium and those who did not [χ2(1, N = 95) = 4.7, P < 0.05]. Of all patients who developed delirium, 94.7% required nursing care, whereas only 70.7% of those who did not develop delirium required nursing care (Table 1). Eighty-four (88.4%) of the patients had hypertension. Eighteen (18.9%) patients had ischemic heart disease. Twenty patients (21.1%) had experienced a stroke. Thirty-five (36.8%) patients had diabetes. Twenty (21.5%) patients had significant renal failure, defined as a Creatinine Clearance Test (CCT) rate assessed as less than 40. The CCT mean was 63 (SD = 24.7), with a range of 10–99, and a significant mean difference in the estimated CCT between patients who developed and did
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Delirium and rehabilitation Heyman et al. 235
Table 1
Differences in the functioning (ADL) of patients who developed delirium and patients who did not develop delirium
ADL at admission Patients who did not develop delirium Patients who developed delirium ADL at discharge Patient who did not develop delirium Patients who developed delirium
Requires nursing care [n (%)]
Debilitated [n (%)]
χ2
d.f.
Significance
53 (70.7) 18 (90)
22 (29.3) 2 (10)
4.7
1
> 0.05
23 (41.1) 15 (75)
33 (58.9) 5 (25)
5.7
1
> 0.05
ADL, Activities of Daily Living.
not develop delirium [t(92) = 2, P < 0.05]. Patients who developed delirium had a lower mean CCT [M = 53.1 (SD = 23.4)], than patients who did not develop delirium [M = 65.7 (SD = 24.7)]. Fifty-seven (60%) of the patients had comorbidities, with more than three significant diseases (diabetes, cardiovascular diseases, stroke, and renal failure). No significant difference was found in comorbidities between patients who developed delirium and those who did not (P > 0.05). Twenty-one (22.1%) patients had previous fractures. The mean BMI of patients was 26.5 (SD = 6.7), with a range of 17–49. Seventy-five (78.9%) patients took hypertension medication. Fifty-four (56.7%) patients took narcotics. Thirty-one (32.6%) patients took benzodiazepines. At admission, 20 (21.5%) patients developed delirium. This included four patients who developed full delirium according to the CAM and DRS-R-98 criteria and 16 patients who developed subsyndrome delirium. The mean duration of the patients’ delirium was 21.9 days (SD = 14.6), with a range of 7–54 days. Nine (8.5%) patients developed delirium on the last day of hospitalization. There was a significant difference between patients who did not develop delirium and those who developed delirium in their level of FIM at admission [t(92) = 2.8, P < 0.01]. The mean FIM at admission was lower among patients who developed delirium (M = 51.6, SD = 16.3) than among patients who did not develop delirium (M = 64.1, SD = 17.2). Twenty-seven patients had a cognitive impairment of under 23 MMSE at the time of admission. There a significant difference between patients who did not develop delirium and those who did develop delirium [t(90) = 3.8, P < 0.05], with the MMSE at admission having been on average lower among patients who developed delirium (M = 12.6, SD = 6.3) than among patients who did not develop delirium (M = 19.3, SD = 8.1). Significant differences were found in the rehabilitation outcomes of the two groups on several parameters, as presented in Table 2. FIM at discharge and delta FIM were higher among patients who did not develop delirium compared with patients who did develop delirium. Overall, 75% of patients who developed delirium required nursing care at discharge, whereas only 41.1% of the patients who did not develop delirium required
Differences in FIM and DFIM as well as length of hospital stay between patients who developed/did not develop delirium
Table 2
Fracture patients who developed delirium
FIM at discharge Delta FIM Hospital stay (days)
Fracture patients who did not develop delirium
SD
M
SD
M
t
d.f.
18.3
62.4
20.5
83.9
Significance 0.01
3.7
71
13.1 10.7
10.5 29.5
15.4 14.4
19.4 28.1
0.05 > 0.05
2.3
71
DFIM, delta Functional Independence Measure; FIM, Functional Independence Measure.
nursing care [χ2(1, N = 95) = 4.7, P < 0.05]. No significant difference was found between the hospital stay duration of patients who developed delirium and those who did not. Moreover, no significant difference was found between patients who were discharged to their homes and those who were discharged to other facilities (P > 0.05).
Discussion The research findings showed that about 30% of patients hospitalized in a rehabilitation ward following a hip fracture developed delirium during their hospital stay. This prevalence was similar to that reported by Schuurmans et al. (2003), who found that 27 of 92 patients at a geriatric rehabilitation ward developed delirium. Nonetheless, other studies reported a higher prevalence. Radinovic et al. (2014) reported that 53% of hip fracture patients older than 70 years had delirium during their hospital stay at an orthopedic ward. Meta-analyses carried out among hip fracture patients who developed delirium indicated a widely diverse prevalence. Variable prevalence was also reported as evident from the systematic literature review of Siddiqi et al. (2006), who found that the prevalence of new delirium cases among in-patients ranged from 3 to 29%. Olofsson et al. (2005) presumed that the variance in the prevalence of delirium in various studies of elderly hip fracture patients may have been associated with factors such as inclusion criteria and the ability to detect delirium. Delirium still appears to be an underdiagnosed clinical syndrome. The transient and varying nature of the symptoms and the heterogeneous profile of delirium, with its different subtypes, contribute
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236 International Journal of Rehabilitation Research 2015, Vol 38 No 3
toward this underdiagnosis (Witlox et al., 2010; Inouye et al., 2014).
disruption of neuron functioning, which may explain the appearance of delirium.
The research findings indicated several risk factors for developing delirium among posthip fracture elderly patients in geriatric rehabilitation. These could be categorized as sociodemographic, functional, and cognitive risk factors. Two sociodemographic risk factors were older age and being Jewish. The current study found that patients who developed delirium were on average older than patients who did not. Indeed, studies have shown that older age is a known risk factor for delirium among hip fracture patients (Schuurmans et al., 2003). Jewish patients had a higher risk of developing delirium. There were no other significant differences between Arabs and Jews that can explain the difference in the prevalence of delirium between the two populations. No studies were found on differences between Arabs and Jews in the incidence of delirium. This difference may have been a result of the difficulty in detecting delirium among Arab patients because of difficulties in fully communicating with patients who speak Arabic as their first language. The diagnostic tools for delirium may also not be suited to the Arab culture (Inouye et al., 1990).
The research findings indicated better rehabilitation outcomes among patients who did not develop delirium. FIM at discharge and delta FIM were higher among patients who did not develop delirium than among those who did. Furthermore, a different level of basic ADL functioning at discharge was observed, that is, more patients who developed delirium required nursing care at discharge. These findings showed better rehabilitation outcomes among hip fracture patients who did not develop delirium than among those who did. Many studies have indicated the association between delirium and various measures of rehabilitation outcomes (Olofsson et al., 2005; Siddiqi et al., 2006; Guerini et al., 2010; Witlox et al., 2010; Martinez Velilla and Franco, 2012; Cole et al., 2013; Liang et al., 2014; Uriz-Otano et al., 2014). Nonetheless, the exact mechanisms responsible for the association observed between delirium and poor rehabilitation outcomes among patients who developed delirium have not been clear. Several explanations were suggested for this finding: one of these was that a prolonged episode of delirium might contribute toward higher morbidity and complications, which may have led to poor rehabilitation outcomes. The duration of the symptoms might have indicated that the basic disease was still active or has worsened. Alternately, the delirium itself or the factors that stimulated the delirium syndrome may have led to a chain of events in the brain, possibly hampering the patient’s rehabilitation capacity (Witlox et al., 2010). The presence of dementia may itself have been detrimental to the rehabilitation process because of cognitive deprivation, such as of executive ability, memory, and attention. The combination of dementia with the delirium syndrome may have led to severe cognitive deterioration. This severe deterioration may have been responsible for poor rehabilitation outcomes among elderly hip fracture patients (Morandi et al., 2014). Another explanation for this finding may have been rooted in caregivers and particularly the nursing staff, who considered delirious patients with cognitive and nursing care deterioration to be more dependent and to require more complex nursing care. This recognition led the nursing staff to provide care that perpetuated the patient’s dependency to save time and labor, and thus they did not provide these patients the opportunity to perform daily activities at their own pace, thereby creating a state of dependency (Olofsson et al., 2005).
Functional risk factors for delirium were lower FIM at admission and lower prehospitalization ADL. In the current study, patients who developed delirium had on average a lower FIM at admission than patients who did not develop delirium. A larger proportion of patients who developed delirium required nursing care at admission than patients who did not develop delirium. Similar to other studies carried out among hip fracture patients (Olofsson et al., 2005; Radinovic et al., 2014), this study found that older patients in a poorer physical state had a higher risk of developing delirium following a hip fracture. The current study found that patients with cognitive impairment (MMSE
